How to Get Started on Your Gender Transition

Everything you need to know about insurance coverage of transgender and gender non-binary medical care.

This is part of Tonic’s Healthcare Guide series. See the other guides here, and find the glossary here. Download the PDF version of this guide here and a find a PDF of the master document here.

There is no one, correct way to transition genders or path to get there. Begin by talking it out with a trans and gender non-binary (TGNB) affirming therapist for a while? Great. Lead with hormones for six months and then see how you feel? Awesome. Start with chest surgery and a name change, then call it a day? Do you!

Regardless of what you feel your next steps are, the services you can access depend on where you live and insurance coverage. If you’re feeling overwhelmed about figuring out where to begin, or just need a little help understanding the insurance aspect, trust that many other TGNB people have been in the same boat, and there are resources to help you.

Who decides if I’m trans or non-binary enough to get medical treatment?

At the end of the day, each surgeon or hormone provider makes their own choices about providing care. You might not need to see a mental health provider at all. The requirement for counseling has its roots in the university-based gender clinics of the 1960s and 70s, where a TGNB person would be tested and treated by a team of mental health providers before being deemed a “true transsexual” and granted (or, more often, denied) medical treatment.

The World Professional Association of Transgender Health (WPATH) formalized these early attempts to do TGNB medicine into a Standards of Care that gets updated periodically with changing times. The most recent version from 2011 has done away with many former requirements, like the “real-life test” of first living publicly for a specific amount of time in your identified gender before obtaining medication and surgery.

The current Standard of Care even acknowledges that “informed consent” to start hormones is a perfectly reasonable way of doing things. This is when a primary care provider assesses if you’re able to comprehend the risks and benefits of treatment without a mental health evaluation. Informed consent clinics are in many major metropolitan cities, but there are still geographic areas where the only providers who will prescribe TGNB hormones require you to get a referral letter from a therapist. Some therapists, including those who work across the US via Skype or other online platforms, may write these letters after a single appointment, depending on your mental health history.

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So how do I find one of these therapists or medical providers?

WPATH maintains a directory of medical providers and therapists who are active members. Community organizers have set up a number of websitesaiming to createproviderdirectories. Word of mouth is another way to look for and vet providers, asking at in-person or online communities, like groups on Reddit and Facebook, and at LGBT organizations that serve your area.

If you are in crisis and live in the United States or Canada, the Trans Lifeline (877-565-8860) is one immediate resource.

I’m nervous about my first visit!

Sadly in 2018 it’s still reasonable to be worried that a medical provider won’t take you seriously, will actively discriminate against you, or will simply not know how to provide your TGNB-specific healthcare. A relationship with a medical provider is a partnership with shared decision-making and shared responsibility. A good provider will be happy that you’re taking the initiative to get involved in your health, regardless of their own knowledge of TGNB care. If a provider discriminates against you by not offering services they would offer a cisgender (or non-transgender) person, it could be in violation of state and federal law, in addition to being in violation of professional ethics codes. If a provider is willing to learn how to provide for your TGNB-specific needs, you can point them toward onlineresources for medical providers to learn more.

On a path as individual as gender transition, even with the most TGNB-informed medical providers, you still have to speak up to get what you need. Aria Sa’id, senior policy advisor at the San Francisco Human Rights Commission and founder of the Kween Culture Initiative, encourages TGNB people to get behind the wheel of their own healthcare.

“We go into medical spaces believing that medical providers are the experts on our health, and unfortunately it just doesn’t work that way. Really medical providers are able to, for lack of a better analogy, sell you the car, but you have to tune it up and you have to do oil changes and tire checks. You are the expert on your own healthcare, and your medical provider is just a guide to getting better.”

Will my insurance pay for this?

Regardless of whether you have insurance through your employer or you bought an Obamacare plan, it will probably cover doctor’s appointments, meds, and surgery, says Noah Lewis, executive director of Transcend Legal and a legal expert on TGNB healthcare. “There might be a denial or appeal process that you have to go through, but the law is on your side and you should feel empowered to demand the coverage that you are entitled to,” he says.

Lewis is one of the movement experts using the patchwork of state and federal laws to expand access for those who have an insurance policy stating that TGNB care will not be covered. Starting in 1981 the federal program for seniors and disabled people Medicare was in this category. In 2014, however, a legal challenge to Medicare’s policy was successful, and we have continued to see gains in coverage since.

Transcend Legal has an easy-to-follow video guide to using insurance to access TGNB care. Federal Medicare now covers TGNB care, as does Medicaid in many states. While movement advocates are working on policy and litigation that we hope will ensure clear, national coverage, 10 states explicitly exclude TGNB care from Medicaid coverage and many private plans still carry blanket exclusions for TGNB care.

The same considerations apply to using your health insurance for TGNB care as they would for any service. It is very common for requests for coverage to be given an initial denial, as Lewis notes, even if the policy says it is clearly covered. If your insurance approves the surgery or medication, it’s important to know that there will still be costs like deductibles and copays built into the plan, unless you’re on a version of state Medicaid. You may also be limited to in-network providers (doctors in a network that contracts with your insurance), or to services in your state if you have Medicaid. However, if your insurance covers a service but has no one in-network to provide the service, it is possible to claim a “network deficiency” to access another provider. And while it was once the most affordable option to fly overseas for surgery, if you’re planning to use insurance, there is essentially no chance of being reimbursed for international care.

Do I need to change the name or gender marker listed on my insurance?

There isn’t a blanket answer to this. In the course of my work as a case manager at Callen-Lorde Community Health Center in New York, I’ve seen billing hiccups happen both because the gender marker was changed and because it wasn’t. Don’t delay changing your documentation now because of a theoretical problem accessing medical care later. Do check your insurance mail, and don’t be afraid to pick up the phone (or have a bossy friend help you with the call) if you get into a billing headache.

Is there a risk that insurance coverage for TGNB care will get taken away?

With news of a Trump administration memo that, if put in place, would affect the way the federal government defines sex, many people are nervous about how it could impact TGNB health insurance gains. It’s important to keep in mind that the federal government’s definition of sex is not the only tool advocates have been using to expand TGNB coverage.

“When you hear [that] any day now that administration is trying to roll back the nondiscrimination protections under the Affordable Care Act (ACA), you should know that it’s only a proposal, not the law, and it might not go through,” Lewis says. “There are many other laws that protect people, so it’s a pretty minor thing. The ACA itself is still in place, you still have rights, regardless of what you hear in the news. There are many other laws and you should appeal denials and exclusions.”

Other expertsconcur with his viewpoint while talking more specifically about the memo’s possible reach. As we wait to see how this proposal will unfold, know that courts have continued to decide TGNB care must be covered.

What if I don’t have insurance?

If you’re trying to access primary care and medications, Federally Qualified Health Centers (FQHCs; you can search a nationwide database here) and many public hospitals have sliding-scale fees for uninsured people, and they have access to government programs to make medications cheaper at their in-house pharmacies. It’s also worth looking at GoodRx to see what the best prices are for your medications in your area. It might end up being cheaper to purchase insurance that covers TGNB care, especially if you expect to have bigger-ticket costs like surgery. Every year Out2Enroll reviews Affordable Care Act (ACA) marketplace plans in different states for TGNB coverage and they can help connect you to a TGNB-friendly health navigator in your state.

Some people also try to get a job at a company that’s known to have TGNB-inclusive benefits, but it’s still possible to experience an initial denial through any coverage. The key is understanding that it’s a process, and as long as you keep on top of insurance mail and connect to oneofthemanyadvocates fighting for TGNB coverage (including Transcend Legal, Lambda Legal, and the ACLU) you should be able to come out the other end victorious.

What is the process like for getting transgender surgery?

Unfortunately, the historic lack of coverage in the United States has led to few trained surgeons and a lot of patients waiting to see them. Callen-Lorde Community Health Center, one of the largest providers of TGNB primary care in the country, published a listing of surgeons updated in 2018, including information about insurance coverage. Particularly for genital surgery, it’s very common for surgeons to have waiting lists longer than a year, and the most experienced and reputable surgeons have waiting lists three years long. The waiting period can be used to get all your ducks in a row, insurance-wise, to be sure that everything goes well.

This is a boom period for new surgeons offering care in the United States, but not everyone has the same training and experience. Unlike in Europe and other countries that have been performing TGNB services in mainstream, academic medical centers for decades, surgeons in the US haven’t been publishing peer-reviewed evidence about their outcomes and rates of complications until recently. There is no specific board certification or required training process that certifies surgeons offering TGNB surgery. For the time being, prospective patients need to ask careful questions, and at a certain point, go with their gut in the absence of hard data. It’s best to consult with several surgeons before making a final decision.

Your surgeon and your insurance plan will likely require referral letters from mental health providers clearing you for surgery. The WPATH guidelines state that one letter is needed for chest surgery and two for genital surgeries, but insurance companies may pile on additional requirements beyond the guidelines. While this can feel like yet another hoop to jump through, ideally you’ll have access to someone who can actually help you plan for the adjustment period to your new body that follows surgery, and serve as a resource after surgery if you encounter more problems than you expected. Some people experience depression after surgery, and it can be especially confusing and isolating to feel sad after you’ve finally gotten the procedure you’ve been waiting for. Set up a recovery plan, with a mix of professionals, family, and peers who can be in your corner.

You’ll also need to save up to take enough time off work to recover fully. If you’re eligible for the Family and Medical Leave Act (FMLA), it covers TGNB surgery leave. Additionally, any short-term disability coverage should cover leave for TGNB surgery. The paperwork to get these benefits could out you to your human resources department, but it doesn’t have to. While the forms require your provider to make a statement of “relevant medical facts” regarding your need for leave, depending on the surgery, your provider may be able to find a way to describe your case without using language specific to TGNB care.

What about non-binary surgeries? Surgeries sometimes considered cosmetic like facial surgeries? Voice surgery? Surgeries for minors?

These surgeries have been covered by insurance in some contexts, including certain state Medicaid plans. While some plans explicitly deny that facial surgeries are a part of covered TGNB services, some individuals have fought their plans to argue for coverage. Even if your insurance says loud and clear these surgeries are covered, expect to have a harder time finding surgeons and a longer denial and appeals process. For something like Facial Feminization Surgery, your letters will need to make a persuasive argument that the procedure is treatment for gender dysphoria, not a cosmetic improvement. Minors seeking all kinds of TGNB care mentioned in this story, from hormones to surgeries, need to have their legal guardian's consent. For other services like fertility preservation, if it’s not covered for cisgender people on the same plan, it is very unlikely you will be able to win coverage. If your plan does cover those services then TGNB people have a right to them, too.